# Courier delivery of antiretroviral therapy: a cohort study of a South African private‐sector HIV programme

## TL;DR

A study in South Africa found that delivering antiretroviral therapy via courier was linked to better HIV treatment outcomes compared to traditional methods, especially before 2016.

## Contribution

This study is the first to evaluate the impact of ART courier delivery on viral suppression in a South African private-sector HIV program.

## Key findings

- Courier delivery of ART was associated with a 5% higher odds of viral suppression compared to retail dispensing.
- The association was strongest in 2011–2013 (adjusted OR 1.37) and weakened over time, becoming neutral in 2020–2022.
- Overall, 90.1% of viral load tests showed suppression, with 42% of tests occurring during courier delivery periods.

## Abstract

Courier delivery has become a popular antiretroviral therapy (ART) distribution method in some HIV care settings, yet data on ART courier delivery and how it relates to ART outcomes are scarce. We studied the differences in viral suppression rates between individuals from a South African private sector HIV programme receiving ART by courier delivery and those receiving ART through traditional retail dispensing.

Individuals aged 15 years or older who were actively enrolled in the Aid for AIDS programme between January 2011 and July 2022 were eligible for the analysis. The outcome of interest was viral suppression defined as a viral load (VL) <400 copies per ml. We calculated adjusted odds ratios (OR) for the association between the ART distribution method and viral suppression, comparing those receiving refills through courier pharmacies versus retail dispensing at the time of the VL testing. We used generalized estimating equations to account for repeated VL testing of the same individual. The models were adjusted for age, sex, calendar year, ART regimen, history of mental illness and medical insurance scheme. We computed adjusted ORs for the calendar periods 2011−2013, 2014−2016, 2017−2019, 2020−2022 and overall.

We extracted 442,619 VL measurements from 68,720 eligible individuals, 39,406 (57.3%) were women. The median number of VL measurements per individual was 6 (IQR 3−10). VL suppression was detected in 398,901 (90.1%) tests, and 185,701 (42.0%) of the tests were taken while the individual was receiving ART by courier delivery. Overall, courier delivery was associated with 5% higher odds of viral suppression than retail dispensing (adjusted OR 1.05, 95% CI 1.02−1.08). The strength and direction of this association varied by calendar period, with an adjusted OR of 1.37 (95% CI 1.27−1.48) in 2011−2013 and 1.02 (95% CI 0.97−1.07) in 2020−2022.

Courier delivery of ART is a viable alternative to retail dispensing in the South African private sector, as it was associated with higher viral suppression until 2016 and similar suppression rates in recent years. Further research is needed to investigate the potential benefits and drawbacks of courier delivery of ART in both private and public healthcare settings.